One size does not fit all. It never really has. There is now something we can do about that.

By Todd Ricketts, PhD

With the current and future changes in hearing healthcare, we have a newfound opportunity and increased flexibility for individualized care. Whether we are considering the level of service or the application of advanced hearing aid processing, one size does not fit all. Here is a brief summary of the research about how hearing care professionals can make meaningful differences in the individual care of consumers who are using amplification products—regardless of whether these are OTC or traditionally dispensed hearing devices.

Recent events leading to the soon-to-be released FDA guidance for the category of over-the-counter (OTC) hearing aids have sparked considerable discussion regarding the role of professional services in the habilitation of individuals with hearing loss.1,2 Technological advances also allow for improved access to hearing healthcare. These advances include the automation of hearing testing3 and hearing aid fittings,4-6 teleaudiology-based distance support of hearing aid adjustment,7 hearing aid orientation, and follow-up care.8,9 

However, such advancements also further disrupt traditional hearing aid service delivery models. Research has demonstrated that automated systems are currently able to accurately evaluate hearing thresholds, program appropriate hearing aid gain and output parameters, and provide basic use counseling and orientation for a subset of our patients. 

Despite these advances, many patients struggle with the hearing aid acquisition and fitting processes without professional help.10,11 Indeed, even in a future where many hearing aids are completely automatic and self-fitting, there will still be a substantial number of patients who need professional guidance for hearing aid orientation and use counseling. 

Surveys show the vast majority of individuals who have already obtained hearing aids through traditional service delivery models greatly value these services.12 Consequently, many of our future patients are likely to want a professional to complete even the most basic parts of the hearing aid acquisition process. It is expected that some patients who desire a full-service model will respond well to automation of a portion of these traditional hearing healthcare services (eg, hearing threshold testing, real-ear gain and output adjustment, basic orientation, etc) as well as distance-based follow-up care. Other patients, however, will desire only limited professional services. 

Finally, there is little doubt that at least some patients will want to obtain hearing aids without any professional help. However, a portion of these patients may find they would like some professional support after purchasing devices. 

In this near future, the hearing healthcare professional (HCP) will have the opportunity to not only individualize patient care, but also individualize the level of service provided based on patients’ needs and desires—ranging from limited services models which might include selection support, fine tuning, and use counseling, to currently common service levels and beyond. Importantly, the implementation of automated services and limited services models will result in an increase in service efficiency. Therefore, this presents a considerable opportunity for the HCP to not only serve more patients, but also to provide enhanced and individualized services to those patients who desire, and can benefit from, advanced care that extends well beyond what is currently offered in many clinics. 

After decades of research and development leading to an improved evidence base,13 coupled with the current and future changes in hearing aid services, there is certainly increased interest in enhancing patient care through expansion of aural rehabilitation services in adult patients. Aural rehabilitation services have long been shown to be beneficial for many adults with hearing loss14; however, a lack of reimbursement has often stymied efforts to provide these services. Consequently, many professionals have been forced to limit “aural rehabilitation” to device-related services focused around device orientation, use counseling, and follow-up troubleshooting. However, with the increasing evidence base in this area, expansion of aural rehabilitation services continues to be a potentially viable direction for HCPs and clearly would be beneficial for at least a sub-set of new hearing aid users.  

One area of study that has received considerably less attention is professional services aimed at individualizing selection, adjustment, and use-counseling of devices. Is it enough for the HCP to adjust hearing aid intervention strategies based primarily on hearing thresholds, cosmetics, and financial considerations, or are there other considerations? There are at least three questions that are important to address relative to individualization of patient care in this area: 

  1. Do different hearing aids or different settings produce different outcomes depending on how patients use them?
  2. Do different patients have different preferences for how their hearing aids are programmed in the same environment? 
  3. Are there individual patient factors that might help the HCP predict how to best select, program, and counsel for optimal outcomes for each individual patient? 

Our lab and a few other research groups have been tackling these and related questions over the last few years. One somewhat surprising finding is that different patients do have different preferences in the same listening environments, and these preferences are somewhat predictable based on individual differences (Erin Picou, PhD, and I are currently preparing a paper on this topic). One important caveat, however, is that the performance differences for the different hearing aid settings need to be large enough to be noticeable by patients. 

The types of technologies that meet the criteria of demonstrating performance and/or preference differences across individuals include: 

These individual differences are more likely to be addressed in an HCP service delivery model than an OTC self-service model. While more research is needed, data from these and other emerging studies suggest: 

  1. Individuals who have poor speech understanding in noise are likely to prefer technologies that increase SNR the most (eg, bilateral beamformers, remote microphones); in contrast, those with excellent speech understanding in noise may prefer omnidirectional processing or weak directional processing for most common listening environments. 
  2. Telephone streaming to both ears while disabling the hearing aid microphones will provide the best performance in noise; however, this configuration will limit a patient’s ability to monitor their environment. Therefore, the patient’s difficulty level while using the telephone, noise levels in the listening environment, monitoring needs, and listening preferences should be considered when configuring these technologies. 
  3. There are many reasons patients may want to wear two hearing aids; however, the magnitude of bilateral benefits (eg, speech recognition in noise, localization, monitoring) decrease with decreasing hearing loss. Counseling and return policies should account for these findings since the majority of patients are primarily being fitted bilaterally. 

While more data is needed, selection and adjustment of frequency lowering, wind-noise reduction, extended high-frequency bandwidth, audio-streaming technologies, patient interface technologies (eg, smart remotes, sensors, apps, etc), car listening technologies, and music listening technologies are also likely to be improved through professional individualization. 

As we continue to learn more about patients’ preferences, benefits, and predictive factors, hearing healthcare professionals have an increased ability to individualize hearing aid selection, adjustment, use counseling, and follow-up care. With the current and future changes in hearing healthcare, we have a newfound opportunity and increased flexibility for individualized care. Whether we are considering the level of service or the application of advanced hearing aid processing, one size does not fit all. It really never has. However, with increasing evidence and advances in technology and automation, there is now something we can do about that.

Correspondence can be addressed to Dr Ricketts at: [email protected].

Citation for this article: Ricketts T. Individualizing hearing healthcare: New opportunities in OTC hearing aids. Hearing Review. 2020;27(6):16-17.


1. Fulman S, Shapiro Z, Beverly-Ducker K. Choose your OTC device. ASHA Leader. 2019;24(10):46-53. 

2. Taylor B, Manchaiah V. Pathways to care: How innovations are decoupling professional services from the sale of hearing devices. Audiology Today.2019;31(5):17-24. 

3. Mahomed F, Swanepoel DW, Eikelboom, RH, Soer M. Validity of automated threshold audiometry: A systematic review and meta-analysis. Ear Hear. 2013;34(6):745-752. 

4. Convery E, Keidser G, Dillon H, Hartley L. A self-fitting hearing aid: Need and concept. Trends Amplif. 2011;15(4), 157-166. 

5. Folkeard P, Pumford J, Abbasalipour P, Willis N, Scollie S. A comparison of automated real-ear and traditional hearing aid fitting methods. Hearing Review. 2018;25(11):28-32.

6. Mueller HG, Ricketts TA. 20Q: Hearing aid verification—Will autoREMfit move the sticks? https://www.audiologyonline.com/articles/20q-hearing-aid-verification-226-23532. Published July 9, 2018.

7. Pearce W, Ching TYC, Dillon H. A pilot investigation into the provision of hearing services using tele-audiology to remote areas. Austr NZ J Audiol. 2009;31(2):96-100. 

8. Humes LE, Rogers SE, Quigley TM, Main AK, Kinney DL, Herring C. The effects of service-delivery model and purchase price on hearing-aid outcomes in older adults: A randomized double-blind placebo-controlled clinical trial. Am J Audiol. 2017;26(1):53- 79. 

9. Laplante-Lévesque A, Pichora-Fuller MK, Gagné J-P. Providing an internet-based audiological counselling programme to new hearing aid users: A qualitative studyInt J Audiol. 2006;45(12):697-706. 

10. Convery E, Hickson L, Meyer C, Keidser G. Predictors of hearing loss self-management in older adults. Disability and Rehabilitation.2019;41(17):2026-2035. 

11. Convery E, Keidser G, Hickson L, Meyer C. Factors associated with successful setup of a self-fitting hearing aid and the need for personalized support. Ear Hear. 2019;40(4):794-804. 

12. Plotnick B, Dybala P. OTC hearing aids–Survey says consumers aren’t sold. http://www.healthyhearing.com/report/52742-Otc-hearing-aids-survey-says-consumers-aren-t-sold. Published April 6, 2017.

13. Ferguson M, Maidment D, Henshaw H, Heffernan E. Evidence-based interventions for adult aural rehabilitation: That was then, this is now. Semin Hear. 2019;40(1):68-84.

14. Laplante-Lévesque A, Hickson L, Worrall L. Rehabilitation of older adults with hearing impairment: A critical reviewJ Aging Health. 2010;22(2):143-153. 

15. Aspell E, Picou E, Ricketts, T. Directional benefit is present with audiovisual stimuli: Limiting ceiling effects. J Am Acad Audiol. 25(7):666-675. 

16. Picou EM, Ricketts TA. An evaluation of hearing aid beamforming microphone arrays in a noisy laboratory setting. J Am Acad Audiol. 2019;30(2):131-144.

17. Brons I, Houben R, Dreschler WA. Perceptual effects of noise reduction with respect to personal preference, speech intelligibility, and listening effort. Ear Hear. 2013;34(1):29-41. 

18. Huber R, Bisitz T, Gerkmann T, Kiessling J, Meister H, Kollmeier B. Comparison of single-microphone noise reduction schemes: Can hearing impaired listeners tell the difference? Int J Audiol. 2018;7[Sup3]:S55-S61.

19. Picou EM, Ricketts TA. Comparison of wireless and acoustic hearing aid-based telephone listening strategies. Ear Hear. 2011;32(2):209-220.

20. Picou EM, Ricketts TA. Efficacy of hearing-aid based telephone strategies for listeners with moderate-to-severe hearing loss. J Am Acad Audiol. 2013;24(1):59- 70. 

21. Cox RM, Schwartz KS, Noe CM, Alexander GC. Preference for one or two hearing aids among adult patients. Ear Hear. 2011;32(2):181-197.

22. Ricketts TA, Picou EM, Shehorn J, Dittberner AB. Degree of hearing loss affects bilateral hearing aid benefits in ecologically relevant laboratory conditionsJ Speech Lang Hear Res. 2019;62(10):3834-3850.

Other Articles in the OTC Hearing Aids Special Section series below:

Understanding Hearing Aid Rejection and Opportunities for OTC Using the COM-B Model

Meeting the Challenges of OTC: Who Are Self-fitting Hearing Aids Really For?

Tech Trends in OTC Hearing Aids